Does DMDD Take Care of the Over-diagnosis of Bipolar Disorder in Youth?

The following is a section of the JBRF response to the proposal of the new classification DMDD. The response was submitted to the American Psychiatric Association in 2010. This reprint has been edited from the original form. At the time, DMDD was still referred to by its original name; Temper Dysregulation Disorder (TDD). References herein have been changed to DMDD.

The 40-fold increase in children who receive a diagnosis of bipolar disorder has generated great concern. Some believe it represents an over-diagnosis of a serious condition whose boundaries have become fuzzy and thereby confers upon children unnecessary, inappropriate, and harmful impacts. To the degree that this occurs, it is indeed a serious problem that warrants correction. We suggest that an effective way to prevent this from happening is to provide greater clarification as to what a bipolar condition in children really looks like. However, as we are all aware, the research that the Work Groups support has instead given us criteria for what it is not. They have announced with great confidence and media coverage that the new classification called Disruptive Mood Dysregulation Disorder (DMDD) provides a “correction” to erroneous bipolar diagnoses. In so doing, they give the impression that a diagnostic over-sensitivity has now been caught and eliminated; problem solved.

We believe that this is fundamentally wrong and misleading in two ways.

If DMDD is diagnosed carefully and correctly, only a small percentage of children will receive a DMDD diagnosis rather than a BP-NOS diagnosis. In addition to the comparison study noted in the paper which addresses our conceptual concerns with DMDD, in which it was determined that the Broad phenotype is likely subsumed within the Core population, a presentation by Dr. Eric Youngstrom found that less than 5% of the population of Bipolar Disorder Not-Otherwise- Specified (BP-NOS) children analyzed met the Broad criteria established by Leibenluft et al in 2003. (Youngstrom, E, by interview) Therefore, while this re-assignment is presented as the avenue to a major correction; if it is applied accurately its effect may be quite modest and if it is applied liberally (see Clinical Concerns paper) then it may, paradoxically be the cause of significant and troubling misdiagnosis.

The very public announcement is misleading because it gives a false sense of assurance that a major public concern has been effectively addressed. We suggest that two distinct, but equally important concerns currently drive the public conversation:

that there is an alarming increase in children who are seriously ill

that there is an alarming increase in children who we identify as seriously ill

Even if we were to suspend our criticism of the phenotype and assume that the new diagnosis were to improve outcome for many children, it would only be a matter of time until these two concerns surface again.

Regarding concern #1, only if the research that proposed the DMDD classification had concluded that the children who will receive a DMDD diagnosis rather than a bipolar diagnosis are not actually very ill and do not need serious levels of intervention, would it be re-assuring to the public that the increase was due to the misattribution of an acute condition.

But that was not the conclusion of the DMDD research. Again and again, the investigators underscore that children with DMDD are as impaired as children with BD and that they need equally intense support. The fact that the DMDD diagnosis comes with a comparatively rosier prognosis; that these children may out-grow the condition rather than face a life-long debilitating condition, and that the diagnosis may engender comparatively less stigma, does not effectively allay concern over the increasing presence of serious mental illness in children. It just makes it somewhat easier to swallow.

As for concern #2, the investigators and Work Group members never clearly state their expectation as to how this new classification will affect the overall number of children identified with diagnosable conditions. Absent the type of thorough review that was required to create this response, absent an explicit statement otherwise, and in light of the “correction” characterization, members of the general public are likely left with the impression that, on an absolute basis, fewer children will be identified as ill.

This seems to address a general skepticism that we are medicating-away problems that require social attention. However, given the investigators’ characterization of the seriousness and prevalence of DMDD in the general population studies which they examined, one can assume that operationalization of the DMDD diagnosis will result in a lateral rather than downward diagnostic trend.

Therefore, in light of the above criticisms, we do not think that action taken by the proposed changes has, in any real way, addressed important concerns generated by the increase in pediatric bipolar diagnoses. It merely stuns the conversation into a temporary lull until it starts being asked: Why is there such an alarming increase in the number of children diagnosed with DMDD?

In light of the above criticisms, we do not think that action taken by the proposed changes has, in any real way, addressed important concerns generated by the increase in pediatric bipolar diagnoses. It merely stuns the conversation into a temporary lull until the question arises: Why is there such an alarming increase in the number of children diagnosed with TDD?